<%@ Page Language="C#" MasterPageFile="~/MainMaster.master" AutoEventWireup="true" CodeFile="CustomerService.aspx.cs" Inherits="Doctor_CustomerService" Title="Customer Service" %>

<asp:Content ID="Content1" ContentPlaceHolderID="MainTable" runat="Server">

    <script>
<!--
    function popUp(i, ctl, lbl) {
        hndWin = window.open("AccessOptions.aspx?which=" + i + "&ctl=" + ctl + "&lbl=" + lbl, "win", "status=yes,width=400,height=400,toolbars=no,scrollbars=yes");
        hndWin.focus();
    }
    //-->    
    </script>
    <div style="width: 94%; padding: 3%">
        <div style="background-color: #f4f4f4; width: 94%; padding: 3%">
            <table cellpadding="0" cellspacing="0" border="0" style="width: 100%; vertical-align: top">

                <tr>

                    <td align="left" class="bodytxt" style="height: 13px">
                        <asp:Label ID="lblMsg" runat="server" ForeColor="Green"></asp:Label></td>
                </tr>
                <tr>

                    <td align="left" class="bodytxt" style="height: 14px">
                        <p class="page-heading">
                            Service : Submit Ticket
                        </p>
                    </td>
                </tr>
                <tr>

                    <td align="left" class="bodytxt" style="height: 14px"></td>
                </tr>

                <tr>

                    <td class="bodytxt" align="left" style="height: 14px">
                        <!-- Content here -->
                        <p class="page-heading">Simply fill out the below form:</p>
                    </td>
                </tr>
                <tr>

                    <td align="left" class="bodytxt" style="height: 7px"></td>
                </tr>
                <tr id="trErr" runat="server">

                    <td align="left" class="bodytxt">
                        <asp:BulletedList ID="blstErrors" runat="server">
                        </asp:BulletedList>
                    </td>
                </tr>
                <tr>

                    <td align="left">
                        <table border="0">
                            <tr>
                                <td nowrap><b>First Name</b></td>
                                <td>:</td>
                                <td>
                                    <asp:TextBox ID="txtFirstName" runat="server"></asp:TextBox></td>
                            </tr>
                            <tr>
                                <td nowrap><b>Last Name</b></td>
                                <td>:</td>
                                <td>
                                    <asp:TextBox ID="txtLastName" runat="server"></asp:TextBox></td>
                            </tr>
                            <tr>
                                <td nowrap><b>Specialty</b></td>
                                <td>:</td>
                                <td>
                                    <asp:DropDownList ID="ddlSpecialty" runat="server" CssClass="mainselection">
                                    </asp:DropDownList></td>
                            </tr>
                            <tr>
                                <td nowrap><b>Subspecialty</b></td>
                                <td>:</td>
                                <td>
                                    <asp:DropDownList ID="ddlSubspecialty" runat="server" CssClass="mainselection">
                                    </asp:DropDownList></td>
                            </tr>
                            <tr>
                                <td nowrap><b>Address</b></td>
                                <td>:</td>
                                <td>
                                    <asp:TextBox ID="txtAddress" runat="server" TextMode="MultiLine"></asp:TextBox></td>
                            </tr>
                            <tr>
                                <td nowrap><b>City</b></td>
                                <td>:</td>
                                <td>
                                    <asp:DropDownList ID="ddlCity" runat="server" CssClass="mainselection">
                                    </asp:DropDownList></td>
                            </tr>
                            <tr>
                                <td nowrap><b>State</b></td>
                                <td>:</td>
                                <td>
                                    <asp:DropDownList ID="ddlState" runat="server" CssClass="mainselection">
                                    </asp:DropDownList></td>
                            </tr>
                            <tr>
                                <td nowrap><b>ZIP</b></td>
                                <td>:</td>
                                <td>
                                    <asp:TextBox ID="txtZip" runat="server"></asp:TextBox></td>
                            </tr>
                            <tr>
                                <td nowrap><b>Phone Number</b></td>
                                <td>:</td>
                                <td>
                                    <asp:TextBox ID="txtPhoneNumber" runat="server"></asp:TextBox></td>
                            </tr>
                            <tr>
                                <td nowrap><b>EMail</b></td>
                                <td>:</td>
                                <td>
                                    <asp:TextBox ID="txtEMail" runat="server"></asp:TextBox></td>
                            </tr>
                            <tr>
                                <td nowrap><b>Medical School</b></td>
                                <td>:</td>
                                <td>
                                    <asp:Label ID="lblMedSch" runat="server" CssClass="bodytxt" Text="NONE"></asp:Label>
                                    <a id="lnkMedSch" runat="server" href="javascript:void(0)">[Edit]</a>&nbsp;&nbsp;
            <asp:HiddenField ID="hdnMedSch" runat="server" />
                                </td>
                            </tr>
                            <tr>
                                <td nowrap><b>Medical School Graduation Year</b></td>
                                <td>:</td>
                                <td>
                                    <asp:DropDownList ID="ddlGradYear" runat="server" CssClass="mainselection">
                                    </asp:DropDownList></td>
                            </tr>
                            <tr>
                                <td nowrap><b>UPIN</b></td>
                                <td>:</td>
                                <td>
                                    <asp:TextBox ID="txtUPIN" runat="server"></asp:TextBox></td>
                            </tr>
                            <tr>
                                <td nowrap><b>Reason</b></td>
                                <td>:</td>
                                <td>
                                    <asp:TextBox ID="txtReason" runat="server"></asp:TextBox></td>
                            </tr>

                            <tr>
                                <td align="right">
                                    <asp:Button ID="btnSubmit" runat="server" Text="Submit"
                                        OnClick="btnSubmit_Click" CssClass="buttonclass" /></td>
                            </tr>
                        </table>
                    </td>

                </tr>

            </table>
        </div>
    </div>
</asp:Content>
<asp:Content ID="Content2" ContentPlaceHolderID="InnerRight" runat="Server">
</asp:Content>
<asp:Content ID="Content3" ContentPlaceHolderID="FeaturedBox" runat="Server">
</asp:Content>
<asp:Content ID="Content4" ContentPlaceHolderID="ScriptContent" runat="Server">
    <script>
        var frmvalidator = new Validator("aspnetForm", "<%=btnSubmit.ClientID %>");
        frmvalidator.addValidation("<%=txtFirstName.ClientID %>", "req", "Please enter First Name.");
        frmvalidator.addValidation("<%=txtLastName.ClientID %>", "req", "Please enter Last Name.");
        frmvalidator.addValidation("<%=ddlSpecialty.ClientID %>", "req", "Please select Specialty.");
        frmvalidator.addValidation("<%=ddlSubspecialty.ClientID %>", "req", "Please select Subspecialty.");
        frmvalidator.addValidation("<%=txtAddress.ClientID %>", "req", "Please enter address.");
        frmvalidator.addValidation("<%=ddlCity.ClientID %>", "req", "Please select City.");
        frmvalidator.addValidation("<%=ddlState.ClientID %>", "req", "Please select State.");
        frmvalidator.addValidation("<%=txtZip.ClientID %>", "req", "Please enter Zip Code.");
        frmvalidator.addValidation("<%=txtZip.ClientID %>", "num", "Zip Code should be a number.");
        frmvalidator.addValidation("<%=txtPhoneNumber.ClientID %>", "req", "Please enter Phone Number.");
        frmvalidator.addValidation("<%=txtEMail.ClientID %>", "req", "Please enter EMail Address.");
        frmvalidator.addValidation("<%=txtEMail.ClientID %>", "email", "Not a valid EMail Address.");
        frmvalidator.addValidation("<%=ddlGradYear.ClientID %>", "req", "Please select your Medical School Graduation Year.");
        frmvalidator.addValidation("<%=txtReason.ClientID %>", "req", "Please enter a Reason.");
    </script>
</asp:Content>
